Wellworks Enrollment Information

STAFF USE ONLY: 1. Date received: _____/______/______2. Entered—Prospect Tracking: Staff initials______3. Membership Payment: $______Cash ___Visa ___MC __Amex ___Check # ______Gift Cert.# ______ENROLLMENT FORM __New Member __Rejoining Member __Youth Member (ages13-17)

Last Name: ______First Name: ______Middle I: ______

Date of Birth: ______Age: ______Male __Female

Street Address: ______

City:______State:______Zip:______Email:______

Home / Cell Phone: ______Work Phone: ______

MEMBER ID# ______NEW MEMBERS: YOU select any 6-7 digit # for your member ID to be used for computer check-in. 6 REQUIRED, 7 OPTIONAL. (Suggestions: Significant DATE MMDDYY, cell phone#)

Member Type Select ONE and fill out ALL information in that section

__ OU Employee (Current employee, not retired) Group I, II, or IV are benefit eligible. Group III are not benefit eligible and therefore, some of our programs may not apply. 1. Classification: __Administration __Classified __Faculty __AFSCME __FOP 2. OU Department: ______Bldg.: ______Room#: ______

__Spouse/Partner of OU Employee Name of OU Employee: ______Dependent of OU Employee (18 – up to 25 years IF on insurance plan) Name of OU Employee: ______

__OU Graduate/Medical Student *College/School of Graduate Studies: ______

__Community (Athens/local area resident who is not a current OU Employee, OU Spouse/Dependent, or a full-time OU student)

__YOUTH (age 13-17) *Form MUST be signed by parent/guardian on page 3 before permitted to use facility.

SEND COMPLETED FORM: Fax 740-593-0170 Email [email protected] Mail or bring in to WellWorks-Ohio University, E124 Grover Center, Athens, OH 45701  You will be EMAILED within one business day concerning your status.  You will need to go through ORIENTATION before you can begin using the facility/attend classes.  All memberships start on the FIRST of the month in which you join/rejoin.  Visit our website at ohio.edu/wellworks to view our Member Handbook for rules, guidelines, and information MEDICALabout our facility and HISTORY services. Assess your health status by checking all true statements below:

1 HISTORY You have had: Please list all medications you are currently __a heart attack taking: __heart surgery ______cardiac catheterization ______coronary angioplasty (PTCA)/or stent ______pacemaker/implantable cardiac defibrillator ______rhythm disturbance/Afib ______heart valve disease ______heart failure ______heart transplantation ______congenital heart disease ______SYMPTOMS ______You experience chest discomfort with exertion ______You experience unreasonable breathlessness __You experience dizziness, fainting, or blackouts __You take heart medications __You experience ankle swelling __You experience unpleasant awareness of forceful or rapid heart rate

OTHER HEALTH ISSUES __You have diabetes __You have asthma or lung disease __You have burning or cramping sensation in your lower legs when walking short distances __You have musculoskeletal problems that limit your physical activity __You have concerns about the safety of exercise __You take prescription medication(s) __You are pregnant

CARDIOVASCULAR RISK FACTORS __You are a man older than 45 years __You are a women older than 55 years, have had a hysterectomy, or are postmenopausal __You smoke, or quit smoking within the previous 6 months __Your blood pressure is greater than 140/90 mm Hg OR you take blood pressure medication __You do not know your blood pressure __Your blood cholesterol level is greater than 200 mg/dl OR you take medication for you cholesterol __You do not know your cholesterol level __You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister) __You are physically inactive (i.e., you get less than 30 minutes of physical activity on at least 3 days per week). __You are greater than 20 pounds overweight. __You have prediabetes

__ None of these apply

2 I M P O R T A N T : If your health status changes while you are a WellWorks member, please contact our Clinical Exercise Physiology Coordinator to help determine appropriate changes to your exercise program.

Exercise History Do you presently engage in physical activity? __Yes: What kind? ______How often? ______No: Would you be interested in an ORIENTATION on fitness equipment? __Yes __No

How far do you walk each day? __1-2 miles __3-4 miles __More: ______

Do you exercise with weights or resistance equipment? __Yes __No: Would you be interested in an ORIENTATION on weight equipment? __Yes __No

Do you have any exercise limitations? __Yes, explain: ______No Is your occupation: __Sedentary __Active Occupation: ______

Goals Please write down three wellness goals you would like to accomplish. Be as specific as possible. 1. ______2. ______3. ______PLEASE TELL US. . . How did you find out about the WellWorks program? __Radio __Athens News __The Messenger __Email/Constant Contact __Friend/Family/Coworker __ Other: ______

STAFF USE ONLY Risk Factor Stratification: (Check all that apply.) Risk for CVD: __HIGH __MODERATE __LOW ___Age ___Impaired Fasting Glucose Date cleared: ______Initials: ______Family Hx ___Obesity Comments: ______Smoking ______Sedentary Lifestyle ______Dyslipidemia ______Hypertension ______

3 ALL Members: WAIVER AND RELEASE I desire to voluntarily participate in Ohio University's WellWorks program. I understand that during my participation in WellWorks activities, certain dangers exist, such as fainting, abnormal blood pressures, dizziness, and in very rare instances, heart attacks, and/or death. More common injuries include soft tissue injuries--e.g. sore muscles, tendinitis. Every effort will be made to minimize these conditions through pre-participation screening. Should there be any reason to question my health or ability to safely participate in WellWorks, I assume full responsibility in obtaining the advice of my physician. In consideration of my entry into this program, I, my heirs, executor, administrators, and assigns do hereby release and discharge Ohio University, its officers, agents, sponsors, or employees from any responsibility or liability for any subsequent exercise or other activities that I may engage in as the result of attending this program. I understand that any abnormal results associated with my participation in WellWoks activities will be sent to the following named physician, ______, for appropriate follow-up. I attest that I have full knowledge of any and all risks involved in participating in the WellWorks program. I further give permission for Ohio University to use data collected during the program. I understand these data will only be reported in a confidential and anonymous manner.

Signature: ______Date: ______

OU Employees only: BUREAU OF WORKERS' COMPENSATION INDUSTRIAL COMMISSION OF OHIO Waiver of Workers' Compensation Benefits for a voluntary participant in an employer's sponsored recreation or fitness program/activity. This waiver is being completed pursuant to section 4123.01 (C)(3) of the Revised Code, effective August 22, 1986.

Employer: Ohio University The employer and employee shall list below those sponsored recreation or fitness activities for which the employee wishes to waiver his or her rights to compensation or benefits under Chapter 4123 of the Revised code prior to engaging in those activities. Any sponsored recreation or fitness program not listed below may be eligible for Workers' Compensation benefits consideration should any injury occur. Activities: WellWorks, Ohio University's Wellness and Health Promotion Program. All activities that WellWorks may have to offer or any sponsored WellWorks event. The undersigned declares that he or she is a voluntary participant in the employer's sponsored recreation or fitness activity/activities listed above and hereby waives and relinquishes all rights to Workers' Compensation benefits under Chapter 4123 of the Revised Code for any injury or disability incurred while participating on an annual basis on the listed activity/activities. This form must be signed and dated by the employee. The employee will be provided a copy of the signed form, if requested. O/C 0161 (8.86)

Employee's Signature: ______Date: ______

Youth Members (ages 13-17) only:

*Youths (ages 13 – 17) cannot become members without signature from parent/guardian:

Parent/Guardian Name: ______

Parent/Guardian signature: ______Date: ______